Intraductal Neoplasm Research Articles

Challenging dissection during a robotic Whipple procedure extended to the pancreatic body

Presenter: Valentina Valle | University of Illinois at Chicago Background: Intraductal Papillary Mucosal Neoplasm (IPMNs) are lesions with malignant potential. The indication to resection is based on size of the lesion and symptoms. Minimally invasive robotic pancreatic surgery is expanding. Here we present a challenging case of a pancreaticoduodenectomy extended to the body of the pancreas for multiple IPMN lesions. Methods: A 68 year-old female presented with epigastric pain radiating to the back and recurrent chronic pancreatitis. A MRI showed 3 cm pancreatic head lesion and 2 cm pancreatic body lesion concerning for main duct IPMN. Based on size of the lesion and patient symptoms, robotic assisted surgical resection was offered. Extensive adhesiolysis was required to expose the surgical area. Delicate maneuvers allowed a safe dissection of a very difficult uncinate process anatomy. Results: The patient underwent elective surgery for her pancreatic cystic mucinous tumors. The operative time was 450 minutes. Blood loss was 150 cc. Post-operative course was uneventful and the patient was discharged on post-operative day 8. Conclusion: Robotic platform is a valuable tool for complex pancreatic surgery even in the presence of adhesions and challenging scenarios.

Comparative Profiling of Metastatic 4T1- vs. Non-metastatic Py230-Based Mammary Tumors in an Intraductal Model for Triple-Negative Breast Cancer

The transition of ductal carcinoma in situ (DCIS) to invasive carcinoma (IC) in breast cancer can be faithfully reproduced by the intraductal mouse model. Envisaging to use this model for therapeutic testing, we aimed to in-depth characterize the tumor immunity associated with the differential progression of two types of intraductal tumors. More specifically, we focused on triple-negative breast cancer (TNBC) and intraductally inoculated luciferase-expressing metastatic 4T1 and locally invasive Py230 cells in lactating mammary glands of syngeneic BALB/c and C57BL/6 female mice, respectively. Although the aggressive 4T1 cells rapidly formed solid tumors, Py230 tumors eventually grew to a similar size through enhanced proliferation. Yet, ductal tumor cell breakthrough and metastasis occurred earlier in the 4T1- compared to the Py230-based intraductal model and was associated with high expression of matrix metalloproteinase (MMP)-9, vascular endothelial growth factor (VEGF), chitinase 3-like 1 (CHI3L1) and lipocalin 2 (LCN2) as well as an increased influx of immune cells (mainly macrophages, neutrophils and T-cells). Moreover, activated cytotoxic T-cells, B-cells and programmed death-1 (PD-1)-positive cells were more prominent in the 4T1-based intraductal model in line with enhanced pro-inflammatory cytokine and gene expression profiles. Py230-based tumors showed a more immunosuppressed anti-inflammatory profile with a high amount of regulatory T-cells, which may account for the decreased T-cell activation but increased proliferation compared to the 4T1-based tumors. Taken together, our results highlight the differential immunological aspects of aggressive metastatic and non-aggressive intraductal progression of 4T1- vs. Py230-based tumors, providing a base for future studies to explore therapy using these intraductal TNBC models.

An investigation of the classification accuracy of a deep learning framework-based computer-aided diagnosis system in different pathological types of breast lesions.

Deep learning-based computer-aided diagnosis (CAD) is an important method in aiding diagnosis for radiologists. We investigated the accuracy of a deep learning-based CAD in classifying breast lesions with different histological types. A total of 448 breast lesions were detected on ultrasound (US) and classified by an experienced radiologist, a resident and deep learning-based CAD respectively. The pathological results of the lesions were chosen as the golden standard. The diagnostic performances of the three raters in different pathological types were analyzed. For the overall diagnostic performance, deep learning-based CAD presented a significantly higher specificity (76.96%) compared with the two radiologists. The area under ROC of CAD was almost equal with the experienced radiologist (0.81 vs. 0.81), while significantly higher than the resident (0.81 vs. 0.70, P<0.0001). In the benign lesions, deep learning-based CAD had a higher accuracy than both the two radiologists, which correctly classified as benign lesions in 119/135 of fibroadenomas (88.1%), 25/35 of adenosis (71.4%), 14/27 of intraductal papillary tumors (51.9%), 5/10 of inflammation (50%), and 4/8 of sclerosing adenosis (50%). But only the differences between CAD and the two radiologists in fibroadenomas had statistical significance (P=0.0011 and P=0.0313), and the differences between CAD and the resident in adenosis had statistical significance (P=0.012). In the malignant lesions, 151/168 of invasive ductal carcinomas (89.9%), 21/29 of ductal carcinoma in situ (DCIS) (72.4%) and 6/7 of invasive lobular carcinomas (85.7%) were diagnosed as malignancies by deep learning-based CAD, with no significant differences between CAD and the two radiologists. In the diagnosis of these common types of breast lesions, deep learning-based CAD had a satisfying performance. Deep learning-based CAD had a better performance in the breast benign lesions, especially in fibroadenomas and adenosis. Therefore, deep learning-based CAD is a promising supplemental tool to US to increase the specificity and avoid unnecessary benign biopsies.

Histopathological evaluation of minor salivary gland papillary-cystic tumours: focus on genetic alterations in sialadenoma papilliferum and intraductal papillary mucinous neoplasm.

Minor salivary gland tumours showing a predominant papillary-cystic structure are rare, and constitute a mixture of various types of neoplasm; thus, the histopathological assessment of these tumours poses a significant diagnostic challenge. We aimed to delineate the histological characteristics of these tumours and further mutational aspects with a particular focus on sialadenoma papilliferum (SP) and intraductal papillary mucinous neoplasm (IPMN). We retrieved 28 papillary-cystic tumours of the minor salivary glands, and performed histological re-evaluation and mutation analyses of several key oncogenes. The histological classifications were as follows: SP (n=10), SP-like intraductal papillary tumour (SP-IPT) (n=2), IPMN (n=9), intraductal papilloma, cystadenoma, and cystadenocarcinoma (two, three and two respectively). Whereas SP typically consisted of a combination of exophytic squamous epithelium and endophytic intraductal papillary infoldings, SP-IPT lacked the exophytic component. SP and SP-IPT frequently harboured BRAF V600E mutations (75.0%), which were identified in both squamous and ductal components. IPMN was characterised by a well-demarcated cystic lesion filled exclusively with a papillary proliferation of mucinous cells and a high rate of AKT1 E17K mutations (88.9%). Intraductal papillomas were unilocular cystic lesions with intraluminal papillary growth of bland columnar cells. In contrast, both cystadenomas and cystadenocarcinomas showed a multicystic appearance with a papillary configuration. Cystadenocarcinomas invaded the surrounding tissue and were composed of markedly atypical tumour cells. The appropriate interpretation of histological findings and specific genetic alterations (e.g. BRAF V600E and AKT1 E17K in SP and IPMN) would be useful for the correct diagnosis of minor salivary gland papillary-cystic tumours.

2804 Outcomes in Intra-Ductal Papillary Mucinous Neoplasms in the New York Harbor Veteran Population: An Update

INTRODUCTION: Over the last few years there has been an increase in the frequency of findings of intra-ductal papillary mucinous neoplasms (IPMNs). This is likely due to the increased use of advanced abdominal imaging as well as in increase in the quality of these images. In most cases, decisions are based on consensus rather than evidence based as to how to proceed with regard to follow up imaging, biopsy, or even surgical resection. At ACG 2017, we presented the outcomes of and natural history of patients with IPMNs in the Brooklyn VA. Since that presentation, we have an update regarding further data points as well as in increase in the number of patients we analyzed. METHODS: Retrospective chart review was performed on patients with diagnosis, based on coding) of pancreatic cyst, pancreatic lesion, and intra-ductal pancreatic mucinous neoplasm from the New York Harbor Veterans Affairs Hospital from 2000 to 2015. 767 patients were initially flagged, and based on either radiology reports or clinic notes 104 were determined to actually have an IPMN. We looked at basic demographics, risk factors and survival data. RESULTS: Baseline characteristics are outlined in Table 1 of the 104 patients formally diagnosed with an IPMN. In summary, 101 are male. The average age at the time of initial diagnosis was 71.5 years old, the median age was 72 years old. The average Body Mass index was 27.3. The subjects in this study were overwhelmingly African American (40.6%) and White (42.6%). There was a small Hispanic component (14.6%). There were no Asian patients in the study. Nine patients underwent surgical resection. 33 patients died and the median time to survival was not able to be calculated at this time. The average age at the time of death was 78.9 years old. In the 33 patients that died only 6 Patients (5.7% of total patients diagnosed) died from pancreatic causes. CONCLUSION: The management of IPMNs presents a clinical challenge for gastroenterologists today. To date, the levels of evidence in which the current guidelines are based on is poor. Our study is limited by factors such as advanced age, gender and multiple comorbidities preventing further invasive interventions. It is due to these factors, that our study is not applicable to the general population. Therefore, we recommend further larger multicenter trials with a diverse cohort to establish the risk of IPMN’s and their effect on mortality from pancreatic cancer.

Research progress of the relationship between chronic inflammation and pancreatic ductal adenocarcinoma

Studies have demonstrated a strong correlation between chronic inflammation and tumor initiation and progression. Chronic inflammation is mainly involved in tumor progression through intrinsic and extrinsic pathways, and transcription factors such as NF-κB and STAT3 play important roles. Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies. Chronic inflammation can promote the development of PDAC in cooperation with mutation of protooncogene. Inflammation signaling pathway plays an important role in malignant transformation in the PDAC, in which NF-κB and STAT3 are two major transcription factors. Targeting the key regulator points based on the crosstalk between inflammation signaling and PDAC may potentially represent a novel for PDAC prevention and treatment. This article briefly reviews the role of chronic inflammation in the development of PDAC, the PDAC-related inflammatory signal network caused by chronic inflammation, and crosstalk between NF-кB and JAK/STAT3 signaling pathways. Key words: Pancreatitis, chronic; Pancreatic intraductal neoplasms; NF-kappa B; STAT3 transcription factor; Pancreatic neoplasms

Multimodality imaging studies of intraductal tubulopapillary neoplasms of the pancreas.

We aimed to investigate multimodality imaging findings of intraductal tubulopapillary neoplasms (ITPN) of the pancreas. This study was approved by the institutional review board with waived informed consent. A total of eight patients were histopathologically diagnosed with pancreatic ITPN in a single institution over a 6-year period. The imaging findings of dynamic contrast-enhanced computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and positron emission tomography-computed tomography (PET-CT) were reviewed and correlated with clinicopathologic findings. Histopathologically, an invasive carcinoma component was found in 5 of 8 patients (62.5%). The median diameter of the lesions and the main pancreatic ducts were larger in ITPN with invasive carcinoma (19 mm, 13.3-98.0 mm and 13 mm, 5.9-16.3 mm, respectively) than in ITPN without invasive carcinoma (13 mm, 12.7-18.5 mm and 6 mm, 5.6-6.1 mm, respectively), but not significantly (lesions, P = 0.229 and main pancreatic ducts, P = 0.143). Pancreatolithiasis accompanied invasive carcinoma in 3 of 5 patients (60%). Intraductal solid tumors were demonstrated on CT (5/8, 62.5%), MRCP (5/7, 71.4%), and EUS (7/7, 100%). In addition, various imaging findings mimicking chronic autoimmune pancreatitis or pancreatic ductal adenocarcinoma were found in 3 patients (37.5%) on multimodality imaging. The lesion multiplicity and synchronous or metachronous biliary cancer occurred in 3 patients (37.5%), respectively. Patients with associated invasive carcinoma from pancreatic ITPN may have presented a trend toward larger tumor size and dilated pancreatic duct with pancreatoliths, but the difference was not statistically significant. Further studies with a larger number of patients are needed to provide better insight into these findings. Pancreatic ITPN can show various atypical imaging findings as well as typical intraductal solid tumor on multimodality imaging. The presence of lesion multiplicity and synchronous or metachronous biliary cancer can be helpful for assisting with the diagnosis of pancreatic ITPN.

Imaging features of undifferentiated carcinoma of the pancreas.

The purpose of this retrospective study was to evaluate imaging features of undifferentiated carcinoma of the pancreas. The study group included eight patients with surgically resected undifferentiated carcinoma of the pancreas. Multidetector-row computed tomography (MDCT, n=8) and magnetic resonance imaging (MRI, n=6) findings were retrospectively reviewed. On MDCT, all eight cases were hypovascular with upstream main pancreatic duct (MPD) dilatation, and only 1 showed exophytic growth. Five cases (62.5%) showed necrosis/cystic change, and calcification was observed in two cases (25%). Calcification reflected tumour osteoid components. On MRI, haemorrhage and hemosiderin were observed in 4 of 6 (66.7%) cases. In addition, tumour thrombus in the splenic vein (n=1) and intraductal tumour growth in the MPD (n=2) were pathologically identified, although imaging studies only revealed 1 of these latter cases. Undifferentiated carcinoma of the pancreas may present as a tumour with haemorrhagic necrosis. Coexistence of calcification, intraductal tumour growth in the MPD and tumour thrombus may support the imaging diagnosis of this entity.

Abstract LB-140: Myoepithelial-immune cell crosstalk in the transition from non-invasive to invasive breast cancer

Abstract The incidence of ductal carcinoma in situ (DCIS), a pre-invasive malignancy of the breast, has increased in the U.S. since the 1980s, from 3% to 20% of all breast cancer diagnoses. This increase is largely attributed to mammographic screening. Common treatments of DCIS are breast-conserving surgery followed by adjuvant radiation therapy or mastectomy. Further, despite efforts to detect and treat early stage cancer, the incidence of invasive breast cancer (IBC) has not declined, suggesting that many women with DCIS are over treated. Thus, prognostic markers that predict risk of DCIS progression are needed. Genomic studies have yet to find tumor intrinsic alterations that predict DCIS progression to IBC. In contrast, genetic changes in the myoepithelium are found at the transition from DCIS to IBC, suggesting myoepithelial cells may play a role in progression. To investigate the myoepithelium for potential biomarkers, we advanced a non-surgical intraductal tumor cell delivery model in mice using human DCIS.com cells. We reported a progressive loss in myoepithelial differentiation markers p63, calponin, and smooth muscle actin (SMA) prior to transition to IBC, observations that were confirmed in human DCIS. Thus, compromise in the myoepithelium may be an early warning for DCIS at high risk for progression. Here, we hypothesize that the myoepithelial differentiation state informs immune response, and that DCIS lesions with loss of myoepithelial Calponin and SMA will be associated with a pro-tumorigenic immune milieu. This hypothesis is based on observations by us and others showing lymphocyte infiltration in areas where the DCIS myoepithelium has been focally compromised. To address this, we analyzed the expression of 10 myoepithelial and lymphoid biomarkers using multiplex immunohistochemistry to analyze the relationship between myoepithelial cell integrity and immune cells (N=36 cases). DCIS in the background of IBC (mixed DCIS) is assumed to be high-risk DCIS. We find compromised myoepithelial calponin in mixed compared to pure DCIS. Mixed lesions also show reduced infiltration of immune and T-cells, consistent with reduced immune surveillance. However, calponin loss in pure DCIS cases was associated with a decrease in Foxp3+ T-regulatory cells and increase in CD8+PD-1+ T-cells. Next we found that DCIS areas with focal loss of the myoepithelium and micro-invasion showed an increase in immune infiltration, increased T-cells, and increased PD-1+CD8+ T-cells. These data suggest that early compromise in the myoepithelial layer may associate with activation of cytotoxic effectors, consistent with increased immune surveillance. However, since we find T-cell numbers are reduced in mixed DCIS, effective immune surveillance may be dampened with progression. These data support an unreported relationship between myoepithelial cell integrity and the activation state of local immune cells. Citation Format: Elizabeth Mitchell, Sonali Jindal, Tiffany Chan, Jayasri Narasimhan, Sheila Weinmann, Pepper Schedin. Myoepithelial-immune cell crosstalk in the transition from non-invasive to invasive breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-140.

Pancreatobiliary-type intraductal papillary mucinous neoplasm of the pancreas may have 2 subtypes with distinct clinicopathologic and genetic features

We recently experienced cases of pancreatobiliary-type intraductal papillary mucinous neoplasms (PB-IPMNs) with imaging features resembling pancreatic ductal adenocarcinomas (PDACs), and histologic appearance of purely pancreatobiliary morphology and highly distorted papillary growth, which led to the present study aiming to systematically investigate PB-IPMNs in comparison with PDACs. Surgical cases of PB-IPMNs (n = 31) and PDACs (n = 24) were examined. PB-IPMNs were classified into monotypic tumors (n = 12; 39%) consisting of entirely high-grade pancreatobiliary-type neoplastic cells and polytypic cases (n = 19; 61%) associated with components of low-grade dysplasia and/or other histologic types (eg, gastric, intestinal, or oncocytic types). Clinically, monotypic PB-IPMNs less commonly had dilatation of the ampullary orifice (0% versus 74%) and mucin hypersecretion (17% versus 89%) than did polytypic cases. In most cases of monotypic PB-IPMNs, cystic dilatation of the lesional ducts was less obvious on imaging; therefore, 33% were radiologically diagnosed as PDACs. Histologically, intraductal tumors in monotypic cases showed a highly complex papillary architecture with tubular/cribriform glands and irregular branching, and all these cases were associated with invasive malignancy. GNAS mutations were detected in polytypic PB-IPMNs (6/19; 32%), but there were no GNAS mutations in monotypic cases. The recurrence-free survival of patients with monotypic PB-IPMN or PDAC was similar and significantly worse than that of patients with polytypic PB-IPMN. In conclusion, some cases of monotypic PB-IPMNs lacked the classic characteristics of IPMNs and shared features with PDACs, raising the possibility that these cases may be better classified as a papillary variant of PDACs rather than IPMNs.

Intraductal papillary neoplasm of bile duct developed in a patient with IgG4-related sclerosing cholangitis, autoimmune pancreatitis, and myasthenia gravis

In the course of treatment for myasthenia gravis, enlargement of a cystic mass in the liver with peripheral bile duct dilation, diffuse pancreatic enlargement, and serum IgG4 level elevation was identified in a 65-year-old man. Following the diagnosis of autoimmune pancreatitis, a left hepatectomy was performed because of suspected malignancy of the cystic lesion. Analysis of the resected specimen revealed the cystic lesion to be a dilated bile duct. Intraductal papillary tumor comprising fibrovascular stalks covered by neoplastic epithelium was identified in the lesion. Infiltration of IgG4-positive plasma cells was discovered around the cystic lesion. Finally, a diagnosis of intraductal papillary neoplasm of bile duct with IgG4-related sclerosing cholangitis was made. Autoimmune diseases, including IgG4-related diseases, require careful observation because of their potential for malignancy.

Intraductal Oncocytic Papillary Neoplasms: Clinical-Pathologic Characterization of 24 Cases, With An Emphasis on Associated Invasive Carcinomas.

Intraductal oncocytic papillary neoplasm (IOPN) of the pancreas is a rare tumor. Recent molecular data indicate that it is distinct from other intraductal neoplasms; however, its clinicopathologic characteristics, especially the frequency/significance of an invasive carcinoma component, and biologic behavior remain to be fully defined. Clinicopathologic characteristics and survival of 24 IOPNs were analyzed. By definition, all tumors exhibited intraductal growth and oncocytic morphology. The female:male ratio was 1.7, and mean age was 59. In 44% of the patients, the IOPN was discovered incidentally; however, the working diagnosis was "ductal adenocarcinoma" in 42%. Fourteen IOPNs occurred in the head of the pancreas. The median tumor size was 4.5 cm. The tumors often grew along adjacent benign ducts, mimicking invasion, but only 29% exhibited unequivocal invasive carcinoma, mostly in the form of microscopic foci (pT1a=4, pT1b=1, pT2=2), and only 6% had lymph node metastasis. Invasive carcinoma was predominantly composed of small tubular units lined by oncocytic cells, or individual oncocytic cells infiltrating the periductal stroma. Follow-up information was available for 18 patients (median=6.8 y). No patients died from the disease, and the overall 10-year survival was 94%. Patients with invasive carcinoma trended toward a lower 5-year recurrence-free survival than those with noninvasive IOPNs (66% vs. 93%, P=0.066), but overall survival was not impacted by the presence of invasion (P=0.38). IOPN is a distinct tumor type in the pancreas. Despite its morphologic complexity and often extensive pagetoid spread to adjacent ducts, conventional invasive carcinoma is seen in only 29% and usually as microscopic foci. Thus, it is not surprising that IOPN exhibits indolent behavior even when invasion is present.

Su1456 – Assessment of Endoscopic Ultrasound (EUS) and Magnetic Resonance Imaging(MRI) and Serum Levels of Ca199. for Intraductal Papillary Muchinous Neoplasm (IPMN) with Mural Nodules

Su1456 – Assessment of Endoscopic Ultrasound (EUS) and Magnetic Resonance Imaging(MRI) and Serum Levels of Ca199. for Intraductal Papillary Muchinous Neoplasm (IPMN) with Mural Nodules

Tumor Mucinoso Papilar Intra Ductal del Páncreas

Introducción: La aparición de nuevas técnicas de imagen y mayor conocimiento de esta entidad han contribuido para que el diagnóstico del Tumor Mucinoso Papilar Intraductal haya aumentado en la última década. En el presente artículo describimos un caso de un paciente con Tumor Mucinoso Papilar Intraductal de páncreas, hallazgo incidental en Tomografía computarizada de abdomen.&#x0D; Caso Clínico: Se trata de una mujer de 71 años de edad, con antecedentes de Diabetes tipo 2, Hipertensión Arterial Esencial, y cáncer de mama intervenida. En un estudio de control con tomografía computarizada de abdomen se observó un tumor pancreático de 3 x 1.1 cm. Se realizó una punción transagástrica, con lo que se obtuvo una muestra para estudio patológico, el cual reportó una neoplasia mucinosa papilar intraductal.&#x0D; Evolución: La paciente fue sometida a cirugía con la Técnica de Whipple, con duodenopancreatectomía, en donde se retiró la cabeza del páncreas con el tumor adyacente. El estudio de patología confirmó una neoplasia mucinosa papilar intraductal. La paciente no presentó complicaciones post-operatorias y continúa en revisión en consulta externa.&#x0D; Conclusión: Por tratarse de una lesión maligna, el diagnóstico oportuno y correcto fue importante en este caso, para la conducta terapéutica quirúrgica resolutiva.

GNAS but Not Extended RAS Mutations Spectrum are Associated with a Better Prognosis in Intraductal Pancreatic Mucinous Neoplasms.

The management of intraductal papillary mucinous neoplasms (IPMNs) is mainly based on imaging features and clinical symptoms, and remains challenging. The aim of this study was to assess GNAS, RAS family (KRAS, NRAS and HRAS), BRAF, and PIK3CA mutation status in resected IPMNs and correlate it with clinicopathological characteristics and patient survival. Overall, 149 consecutive unselected patients who underwent pancreatectomy for IPMNs were included. After dissection from formalin-fixed and paraffin-embedded tumors, GNAS mutational screening was assessed by allelic discrimination using Taqman® probes and confirmed by SNaPshot analysis. RAS family, BRAF, and PIK3CA mutational screening was assessed by high resolution melt and Sanger sequencing. Gastric- and intestinal-type IPMNs were the most frequent lesions (52% and 41%, respectively). Intestinal-type IPMNs were more frequently associated high-grade dysplasia (49%) and were the only IPMNs associated with colloid-type carcinoma. All pancreatobiliary IPMNs were invasive lesions, located in the main pancreatic duct. GNAS-activating mutations were strongly associated with the intestinal phenotype (p < 10-4), while RAS pathway mutations were not associated with any particular phenotype. Mutations within other members of the epidermal growth factor receptor (EGFR) pathway were very rare (2%). GNAS-mutated IPMNs were rarely invasive (11%) and almost exclusively (83%) of the colloid type. For invasive lesions, multivariate analyses determined that only node negativity was associated with improved cancer-specific survival, but, in univariate analysis, GNAS mutation was associated with prolonged survival. In patients selected for surgery, GNAS mutation analysis and tumor phenotype can help to better predict patient prognosis. In the near future, a more precise mutational analysis of IPMNs might help to better tailor their management.

Occupational cholangiocarcinoma diagnosed 18\u2009years after the end of exposure to 1,2-dichloropropane and dichloromethane at a printing company: a case report

BackgroundCholangiocarcinoma due to exposure to 1.2-dichloropropane (DCP) or dichloromethane (DCM) is classified as occupational cholangiocarcinoma. We report a case of occupational cholangiocarcinoma diagnosed 18 years after the end of exposure to organic solvents at a printing company.Case presentationA 41-year-old man presented to our hospital with jaundice and anorexia. He had previously worked for 6 years at a printing company where an outbreak of occupational cholangiocarcinoma occurred and was exposed to high concentrations of organic solvents during his employment. Computed tomography demonstrated lower bile duct obstruction by the bulky nodal metastasis at the hepatoduodenal ligament with upstream biliary dilatation, an intraductal papillary tumor in the dilated left superior lateral bile duct (B2), and enlargement of the periaortic nodes. Clinical diagnosis of an unresectable invasive intraductal papillary neoplasm of the bile duct (IPNB) with extensive nodal metastasis was made. Although chemotherapy and laparoscopic gastrojejunostomy were performed for the duodenal obstruction, the patient died due to rupture of the tumor. Pathological examination of the autopsy specimen revealed well-differentiated adenocarcinoma at the stromal site along Glisson’s sheath in segment 3, an IPNB lesion without invasion in B2, and biliary intraepithelial neoplasia and chronic bile duct injury at various sites in the large bile ducts. The bulky lymph node (poorly differentiated adenocarcinoma with partial squamous cell differentiation) invaded the bile duct and duodenum.ConclusionsWe report a case of occupational cholangiocarcinoma that developed 18 years after the end of exposure to DCP and DCM. Long-term follow-up is required to carefully survey development of cholangiocarcinoma in workers with an occupational history of exposure to organic solvents.

Biliary interventions using single-operator cholangioscopy.

Cholangioscopy provides an opportunity to directly visualize the bile duct for diagnosing biliary lesions and for therapeutic interventions. Although there are different cholangioscopy techniques available, single-operator cholangioscopy has gained widespread acceptance as the standard technique for interventions in the biliary system because of its ease of use and widespread availability. Single-operator cholangioscopy can be used for both diagnostic and therapeutic indications in the biliary tract. Diagnostic cholangioscopy is used for direct evaluation of indeterminate bile duct strictures with biopsies, diagnosing filling defects in the bile ducts observed during endoscopic retrograde cholangiography (ERC) imaging, preoperative mapping of the precise location and extension of tumors of the biliary tract, and diagnosis of intraductal neoplasms. Therapeutic cholangioscopy is used for visually guided treatment of biliary stones that have failed extraction with conventional ERC techniques, residual or impacted stones by using intraductal lithotripsy, ablation of biliary tumors and for facilitation of guidewire advancement into selective intrahepatic ducts for adequate biliary drainage. In this review, we will focus on advances in the single-operator cholangioscopy techniques in the diagnosis and management of biliary disorders.

A comparison of the Sendai and Fukuoka guidelines for side branch intraductal pancreatic mucinous neoplasms at a single institution

A comparison of the Sendai and Fukuoka guidelines for side branch intraductal pancreatic mucinous neoplasms at a single institution

Covering the Cover

Covering the Cover

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas arising from an intraductal papillary mucinous neoplasm

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells is a rare pancreatic tumor of unclear origin. This case reports a 72-year-old male with bloating and indigestion for about six years who was found to have a 5 cm laterally spreading ampullary mass and a 1.3 cm solid and cystic distal pancreas body mass on esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS). Histological examination of the pancreatic mass showed an undifferentiated carcinoma with osteoclast-like giant cells, contiguous with and apparently arising from an IPMN. Rare areas of glandular morphology within the invasive carcinoma, as well as patchy expression of epithelial markers and close physical association with an IPMN, clearly support an epithelial origin of this neoplasm and also suggest neoplastic progression from a preneoplastic ductal lesion to an invasive carcinoma, similar to the histogenesis of ductal-type pancreatic adenocarcinoma. Molecular analysis of the invasive carcinoma revealed mutations typical of pancreatic ductal carcinoma. Identical mutations were then identified within the intraductal mucinous neoplasm, consistent with origin of this rare pancreatic carcinoma subtype from IPMN.